Gordon Lodge Rest Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed all the quality statements within the key question of safe. We found significant shortfalls in the quality of care and support provided. There were areas of the building which were not clean, people did not always have access to soap and towels to wash their hands. Medicines were not managed safely. Potential risks to people’s health and welfare were not always assessed and there was not always guidance for staff to mitigate risk. Accidents and incidents had not been analysed to identify patterns and trends. However, there were enough staff to meet people’s needs, who had been recruited safely. Staff understood their responsibility to report safeguarding concerns to keep people safe from discrimination and abuse.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

One relative said that their loved one’s care had been reviewed following a change in their condition. They told us that their family member “Was upstairs and moved to the ground floor” which was more appropriate for them.

A member of the management team told us they had a system in place to look for patterns and trends in accidents and incidents. They described this to us. However it was a process to record accidents and incidents rather than learn from them to prevent them from occurring again. Staff told us one person had fallen in the toilet on several occasions and had become entangled with the toilet frame. They confirmed no action had been taken to secure the toilet frame so it gave people the support they needed.

The provider did not have an effective system in operation to analyse patterns and trends in accidents and incidents. The monitoring and recording did not include what type of accident had occurred so it was not possible to see patterns and trends. The immediate action taken had been recorded but there was no review to identify if it had been effective. Two people had between 6 and 8 accidents in a 6 month period, there had been no analysis of these to understand the risks and check actions taken were effective. We analysed the accident records for two people. We found one person had fallen twice in a toilet and the toilet frame had moved on both occasions. However, this had not been noted and action had not been taken to secure all toilet frames so they did not move. Both people had fallen in their bedrooms but no action had not been taken to understand when each person was walking around unsupported and was at risk. Before our assessment a person had left the service without staffs’ knowledge through a fire exit. Following this incident, alarms had been fitted to fire exits to alert staff if they had been used. However, we found the alarm on the kitchen door, which people could access, was deactivated and the door was open.

Relatives gave positive feedback about their family member’s transition into the home. One relative told us that they were worried at first about their loved one settling, they added that their family member had “Never once wanted to go home”.

The provider told us they did not provide staff with detailed information about people and how to meet their needs before they moved into the service. They stated they verbally told staff about information they had gathered during their pre-admission assessment and wrote basic care plans when people arrived. Staff told us they did not know how to meet people’s needs when they moved into the service. They told us they spoke with the person to find out about the support they required. One staff member commented, “Once you get used to them you have more of an idea”. There was a risk people would not receive safe or consistent care as guidance had not been provided to staff about how to meet their needs.

We contacted external stakeholders for comment during our assessment but did not receive any response. We had not received any concerns from partners before the assessment.

Effective processes were not in operation to ensure staff had all the information they needed to provide people’s care and support them to remain independent when they moved into the service. Care Plans and risk assessments providing detailed guidance to staff where not put in place before people moved in. There was a risk people would not receive consistent care and treatment in the way they preferred. The provider had a process in place to ensure people moved safely to other services, this included taking part in assessments, information sharing and ensuring sufficient medicines were in stock.

People we spoke with were happy with the care and support they received. One person told us “Everyone is nice, I’m lucky really”. A relative told us “It’s brilliant, she’s well looked after”.

The provider and manager had met with a lead district nurse following concerns being raised about people’s safety. They had discussed the concerns and it had been concluded that people were not at risk. Staff knew how to identify risks of abuse. They told us they would report any concerns to the provider or manager and were confident they would act. Staff knew how to blow the whistle to the local authority safeguarding team and told us information was available for them to refer to if needed.

People were safely supported. We observed staff talking with people, reassuring them and discussing their concerns.

Some staff had not been supported to complete training in relation to safeguarding. A robust safeguarding policy was in place which reflected the local safeguarding authority policy and processes. The provider had informed the local authority safeguarding team of any concerns they had, so they could be investigated.

People and their loved ones told us that staff managed risks and they felt safe and protected. One relative told us “The staff handle situations that could blow up, they’re on it” another added “Staff are pretty good, especially with what they have to contend with”.

The provider told us they had delegated the responsibility of writing care plans and risk assessments to other members of the management team. Staff were not able to tell us what people’s seizures looked like. They told us they would make sure the environment around the person was safe but did not know when to call for emergency medical care. This left the person at risk of harm. Staff told us they did not regularly read people’s care plans and relied on their skills to meet people’s needs. They told us if people’s needs changed they would change the way they assisted the person and tell the management team the changes they had made. Staff described how they safely supported people to manage catheters and stomas. This included identifying if there was any problems and contacting health care staff for treatment. However, detailed guidance was not in place for new or inexperienced staff to follow. Staff were able to describe how people living with diabetes may look and feel if their blood glucose levels were not within their usual range. However, they were not able to tell us what was ‘too high’ or ‘too low’ and how they would support them. This left people at risk of harm.

We observed staff being available to support people as needed with walking and mobility aids. We also observed people eating their meals independently with staff offering support where needed.

Individualised detailed guidance had not been provided to staff about how to mitigate risks and provide safe care. This included how to support people who left the service without staff’s knowledge, falls risks or epilepsy. Individual risks in relation to diabetes had not been assessed and mitigated. Personalised guidance had not been provided to staff about how to identify if people were at risk of becoming unwell and the action to take. For example, information about the usual blood glucose range for each person and what to do if their blood glucose went outside of this range was not included. Some people required a catheter to drain urine from their bladder. People’s care plans recognised they required a catheter; however, detailed guidance had not been provided about how to care for the catheter. There was no guidance about the signs if the person had an infection or the catheter was blocked and what action they should take. Some people required support to move around, including moving in bed to reduce the risk of their skin becoming sore. No guidance had been provided to staff about how to support people to turn in bed. People were not protected from the risk of developing pressure ulcers. Detailed guidance had not been provided to staff about how frequently to move people to reduce the risk of skin damage. Staff told us one person needed to be repositioned every 2 hours but records showed they had not been supported to do this.

People did not raise any concerns with the safety of the building, or the equipment used to support them.

The provider told us following our site visit that they had fitted a new lock to the back gate and were looking at accessible signage.

Action had not been taken to ensure the environment was consistently safe. We observed a fire exit which led to the rear garden was open during our time on site. Staff confirmed it was open to facilitate ventilation in the kitchen. The area was not constantly monitored and the door was accessible to people. The rear garden gate was not secured and there was a risk people would leave the service without the support and knowledge of staff. There was also the risk the public could enter the building without staffs’ knowledge. In the lounge two packets of button batteries were stored on an open shelf and were accessible to people. Some people were living with dementia and there was a risk these could mistaken for food items and swallowed. Button batteries can cause severe damage to the stomach if swallowed. The manager removed these at our request. Hand rails had been installed in areas of the service and we observed people using these to move around with confidence and support.

The environment had not been planned to support people living with dementia move around without support. There was some clear signage but this was not clearly displayed, for example on the doors to specific rooms. Carpets were patterned, to some people living with dementia or with visual impairments patterned carpets can look like they have objects on them and may lead to disorientation. An environmental risk assessment had been completed, by the provider in February 2024. This was not specific to the building, grounds and equipment used at the service. For example, there was no mention of moving and handling of people, windows restrictors or processes in operation to ensure safe water temperatures before baths and showers. Regular safety checks had been completed on the building and equipment. This included checking fire safety equipment. A new addressable fire alarm system had recently been fitted. Specialist contractors had completed checks on hoists and wheelchairs. A business continuity plan was in place.

People and families we spoke with told us staff were friendly and able to meet their needs. One person told us “Staff are good” and a relative added “We’ve been satisfied, found nothing to complain about”.

The provider told us, “I have been recruiting for another domestic assistant. The staff are generally very good at covering shifts, we do at times use agency staff to fill in the gaps. Some staff do a mix of roles, care, domestic & laundry. [Head of care] and [manager] will also help with short term sickness absence.” They also told us, “The staff have all worked extremely hard to maintain a good standard of care to our residents and ensure all their needs and personal choices are met.” The provider was in the process of recruiting additional staff including care staff and an activities person, they tried not to use agency staff. They said, “I try to avoid this as it puts extra pressure on the staff as agency staff do not know people”. Staff told us any vacant shifts were covered by substantive staff or agency staff. They felt there were enough staff to provide people’s care but they did not often have time to spend with people doing activities. We spoke with the provider about staff training and they confirmed staff had not completed training in relation to catheter, stoma care and epilepsy. Staff required these skills to meet people’s needs.

We observed there were enough staff on duty during the on site visit. Staff were not rushed and took their time with people.

The provider had a process in place to decide how many staff were required during the day and at night. This did not include time for staff to spend with people, doing activities or going out. The provider had a training policy in place but this had not been followed and staff had not been supported to develop the skills they needed to meet people’s individual care needs. For example, staff had not completed training in relation to catheter, stoma care or epilepsy. Some staff have not completed training updates in relation to day to day care tasks such as moving and handling, diabetes and dementia. Some staff had completed recognised qualifications in care, including the care certificate. Staff received regular supervision and appraisals with the provider and had the opportunity to discuss their role and any concerns they had. Safe systems were in operation to recruit staff.

People and their relatives were happy with standards of cleanliness within the home. A relative told us “The girls that look after [them] are good, if [they’ve] got anything dirty on, they change [them]”.

Members of the management team told us it was the responsibility of staff administering medicines to keep the trolleys clean. We asked what checks were completed to ensure medicines were stored in a clean environment and were told no checks were completed. The provider told us they were unaware that the trolleys were dirty and they were “shocked” when they saw them. Following our site visit the provider told us they had put systems in place to ensure the medicines trolleys were cleaned each week. The provider was unaware the garden gate was unlocked and told us they had provided a key to the waste contractor so they could empty the bins when required and prevent the public from having access to the bins. However, they had not checked to make sure they gate was always locked and the bins were secure. Following our site visit the provider told us they had arranged for a new lock to be fitted to the gate. We told the provider liquid soap and paper towels were not available at most hand washing sinks. They told us they were unaware of this and spoke with a staff member. The staff member said they were aware of this but no action had been taken to ensure people, staff and visitors always had adequate hand washing facilities. The provider told us stocks of soap and paper towels were available at the service but had not been used by staff. Following our site visit the provider told us they had put arrangements in place for the laundry to be cleaned and repainted.

Areas of the premises and some equipment were not clean. Trolleys used to store people’s medicines were soiled with dirt and the residue of liquid medicines. We observed a medical devise used to assist someone take medicine from an inhaler was dirty. A trolley used to serve drinks and snacks was also dirty. The edges had not been cleaned and there was a build up of dirt in the corners. The wheels were heavily soiled. Liquid soap and paper towels were not available at many handwashing sinks, including in bathrooms and toilets used by people and staff. The walls and floor of the laundry were rough and not easily cleaned. Walls were covered in a think layer of dust and cobwebs. The sink was heavily stained with limescale. The provider confirmed they would not be happy for their laundry to be washed and dried there. Following our site visit the provider told us they had put arrangements in place for the laundry to be cleaned and repainted. Clinical waste bins were used for the disposal of continence products and other items. These were not consistently emptied when they were full. We observed one bin, in a toilet used by people, to be so full it would not close. It was also malodourous. Clinical waste bins were stored in the rear garden for collection by a contractor. Three of the four bins were not locked as required. The rear garden gate by the bin store was unlocked, leaving clinical waste accessible to people and the public. We observed a rubbish bin in a bathroom did not have a refuse bag in it and had been used to dispose of hair and other items. Next to this was a bag containing hair curlers matted with hair. The provider told us these belonged to the hair dresser who visited to wash and style people’s hair. The provider confirmed these were not acceptable and should not be used. We observed the laminate on some furniture was chipped or broken making it difficult to keep clean. This increased the risk of infections spreading around the service.

Effective processes were not in operation to ensure all areas of the building were kept clean and infection risks were controlled. The provider’s infection control policy did not cover all areas of infection prevention and control. Staff were left without the guidance they needed to ensure all areas of the service were clean and people were protected from infections risks. Some staff had not completed training in relation to infection prevention and control, hand washing and the use of personal protective clothing.

People did not raise any concerns related to their medicines.

The management team told us they had not realised they should be monitoring the temperature of all medicines. They told us they had not been informed of this before, despite it being their responsibility to ensure they were always following good practice guidance, such as guidance from CQC or the National Institute for Health and Care Excellence. We spoke with the management team about guidance for staff around the administration of when ‘required medicines’. They were not aware there was no guidance in place for some medicines, or that guidance for other medicines was not complete. The management team were not aware there were loose tablets in the medicines trolleys and were unable to tell us what the tablets were, who they had been prescribed too and if people had received their medicines are prescribed. They were unaware stock balances of medicines supplied in their original packaging had not been maintained. The provider told us it was senior carers responsibility to ensure all medicines were accounted for. However, they had not checked to ensure this was being done. A member of the management team told us it was staff’s responsibility to record when they had applied prescribed creams. They were unaware staff were not recording this consistently. We asked a member of the management team if they recorded the site of the application of medicated patches to ensure they were used safely. They told us they did and asked a member of staff to show us the records. The staff member said they did not record this information. This left people at risk of harm. Following our site visit the provider told us they had put patch application records in place.

People’s medicines were not always stored safely. Medicines were stored in different areas of the service. The temperature the medicines were stored at was not consistently monitored. Some medicines were stored in warm areas, including next to a radiator, and no systems were in operation to check their temperature. Some people were prescribed medicines ‘when required’, including pain relief and medicines to reduce anxiety. The provider did not have an effective system in operation to ensure detailed guidance was available to staff about when the medicine should be administered, how they would identify it was required and the maximum dose to administer in a 24 hour period. There was a risk people would not receive their medicines when they needed them or would receive too much medicine. The provider sent us two guidelines written after our site visit. However, these did not provide sufficient guidance to staff about safe medicines administration. The provider did not have effective processes in place to make sure handwritten medicines administration records were accurate. Handwritten instructions had not been checked for accuracy and signed by a second trained and skilled member of staff. Effective processes were not in operation to record the application of prescribed creams. Some prescribed creams had not been recorded, others were not recorded consistently. The provider could not assure themselves people’s creams had been applied as prescribed and were effective. Some people were prescribed pain relief patches. No guidance was available to staff regarding their application and the site of the application had not been recorded. This was important as the patches could cause skin irritation if they were routinely applied to the same area. Consistent records were not maintained when people did not require or refused their medicines. This information is used by healthcare professionals when reviewing the effectiveness of medicines and making treatment decisions.